Current through Register Vol. 54, No. 49, December 7, 2024
Section 1245.54 - Noncompensable services and itemsPayment will not be made for the following services and items:
(1) Ambulance transportation to a physician's office or group practice.(2) Ambulance transportation for a medical service which is not covered under the MA Program, except for nonhospital drug and alcohol detoxification or rehabilitation facility services when a recipient presents to a hospital for inpatient drug and alcohol treatment and the hospital has determined that the required services are not medically necessary in an inpatient facility.(3) Ambulance transportation to a clinic, rural health clinic, hospital, skilled nursing facility or intermediate care facility not enrolled in the MA Program, except in an emergency situation. An emergency situation is when an item or service is required to sustain the life of a person or is critical to the health of a person.(4) Ambulance transportation of a deceased person to a morgue or funeral parlor.(5) Ambulance transportation from one medical facility to another, unless it is for the purpose of obtaining necessary medical care which is unavailable at the facility in which the recipient is a patient and meets the requirements in § 1245.52 (relating to payment conditions).(6) Ambulance transportation from one long term care facility to another, unless it is for the purpose of changing the patient's level of care or if the patient is transferred from a facility because its provider agreement has been terminated and the requirements in § 1245.52 are met. Payment is not made if the ambulance is owned by the nursing facility.(7) Ambulance transportation out-of-State, unless the nearest appropriate medical facility is located out-of-State.(8) Ambulance transportation that is available from another insurance or health program of public agency.The provisions of this § 1245.54 adopted October 31, 1980, effective 11/1/1980, 10 Pa.B. 4257; amended November 24, 1995, effective 11/25/1995, and apply retroactively to November 1, 1995, 25 Pa.B. 5241.The provisions of this § 1245.54 amended under sections 201(1) and 443.1(1) of the Public Welfare Code (62 P. S. §§ 201(1) and 443.1(1)).